Provider Demographics
NPI:1891838488
Name:CARLSON, PHILIP JOHN (DC)
Entity Type:Individual
Prefix:DR
First Name:PHILIP
Middle Name:JOHN
Last Name:CARLSON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 W SPENCE ST.
Mailing Address - Street 2:
Mailing Address - City:COLBY
Mailing Address - State:WI
Mailing Address - Zip Code:54421
Mailing Address - Country:US
Mailing Address - Phone:715-223-1511
Mailing Address - Fax:715-223-1411
Practice Address - Street 1:205 W SPENCE STREET
Practice Address - Street 2:
Practice Address - City:COLBY
Practice Address - State:WI
Practice Address - Zip Code:54421
Practice Address - Country:US
Practice Address - Phone:715-223-1511
Practice Address - Fax:715-223-1411
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3466-012111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI000035217Medicare ID - Type UnspecifiedMEDICARE ID NUMBER